Ruminations by a non-academic general surgeon from the heart of the rust belt.

Monday, December 17, 2007

Futile Care

The idea of futile care is shockingly new in the American health consciousness. The fact that it has become controversial is a testament to the amazing advances we've made in critical care and the preservation of life in the face of multiple organ failure and overwhelming sepsis. Patients are now surviving hemodynamic insults that, 30 years ago, would have been obligatory death sentences. It's truly a remarkable feat in scientific and technological innovation. Critically ill patients are leaving hospitals mere weeks after being almost completely supported by machines. Dialysis and mechanical ventilators replace native organs temporarily, allowing for kidneys and lungs to recover. New antibiotics are able to strike at highly resistant "superbugs". ICU's provide a setting of heightened vigilance so that every change is noted. Highly specialized intensivist teams are there to catch the slightest perturbation in patient performance. It's labor intensive, stressful, and extremely expensive; but it often works. We're literally bringing people back from the dead. The question is: how do you know when the situation has become "futile" and what do you do when you reach that threshold?

In the Panda Bear Blog, this issue is addressed at great length in the unfortunately titled post, "Putting Granny Down". Much of the piece is well written and insightful but the essential point is that we spend far too much money on patients who don't derive any benefit from such intervention. He speaks of the 90 year old nursing home patient, demented and incontinent who gets admitted with urosepsis every two months or so, lacks a DNR order and ends up in the ICU with 15 consultants on board managing his/her multiple organ failure, but in the end, merely delaying the inevitable. Point taken. Not a good situation. Not a good use of limited resources. But put Granny down? Did granny ask to be in this situation? Is it her fault that she's "such a burden" to society? Isn't there a more dignified way to handle the last days of a human being? The reality of the situation is that most ICU's aren't filled with 90 year old demented bags of bones. Believe it or not, there's actually humans in those rooms. Humans across the age spectrum with families and and lives and pasts and even hopes for the future. That hope depends on the efforts of the doctors and nurses providing meticulous, round the clock care. And it ain't cheap. Good outcome or no.

I won't pretend to have all the answers. ICU's will always be expensive. The latest chemotherapy drug will always be expensive. The newest titanium product in hip replacement surgery will always be expensive. The idea that innovation in medicine will be rewarded financially drives much of the research and development that goes on in BigPharm, biotech, and engineering firms. This is a good thing. The high cost of American health care is more a function of the high quality of cutting edge American health care, rather than of wasteful spending on barely conscious Gomers. The problem isn't granny getting too old. The problem is we don't have a system in place to handle this emerging paradigm of how people die. The days of grandpa passing away peacefully at the family homestead of "natural causes" is becoming more and more rare. The elderly are dying with increasing frequency in hospitals and nursing facilities. Death has become a public burden, witnessed by nurses and aides and doctors, and, as a result, has become much more expensive. So what can we do?

1.Make a law requiring every American to have power of attorney/living will/advanced directive documents complete by a certain age. You can't drive without car insurance; why is it ok to enter the twilight of life unprepared for the inevitable decline? At age 60 or so, you sit down and decide what you want to happen when you become ill or are unable to make conscious decisions on your own. Seems simple enough, right?

2. Patients who are deemed unsalvageable, but not close to death (think of the 75 year old guy with good cardiac function who has suffered a major stroke, is dependent on the ventilator, has bed sores, and requires dialysis three times a week but has no idea who or where he is anymore) need to be evaluated by some sort of hospital ethics board. If deemed that ongoing care in the ICU is "futile" then further continuation of such care will need to be paid out of pocket by family members. Major questions arise, obviously, over who this "ethics board" is and why and how they arrive at their decisions. It can be standardized though. If x number of criteria are met, the patient qualifies as a "futile case" and appropriate designation is relayed to the insurance company. The sense of guilt and responsibility is removed from the shoulders of hospitals and health care providers and transferred to involved family members. And maybe that's where it belongs. It may seem cold-hearted, but it's certainly better than "putting down granny".

I think the topic carries with it major philosophical implications. What is life. When is a being not the being he/she was prior to such catastrophic event. The very process of dying has been altered; rather than a quick deterioration and "dying in your sleep", we now face the distasteful possibility of long, slow, drawn out loss of function, viability, and Self. Machines filling in the blanks as your body breaks down. The tissues succumbing to entropy despite the best efforts of science and technology. No one wants to end up like these poor souls who do little more than metabolize in ICU's across the country. Let their unfortunate sufferings be a lesson for our generation. Perhaps dignity and goodness can be salvaged for the future.

The questions are even more loaded (emotionally, etc) on the front end of life. At which week of premature life do you not initiate care, if ever. Many of those medical dollars are spent on neonatal care and then the endless problems some (SOME) have their entire life. None of us have a crystal ball which makes it so very difficult.

Navigating ethical issues is a bit like flying an airplane...the thorniest and most urgent decisions occur at the very beginning and the very end.

A few years ago, I had a patient who was clearly circling a very expensive drain. The family, who had a very different culture than my own or any of the other care providers, didn't trust us and felt that we were advising them to let their loved one go for all the wrong reasons. The resulting prolonged hospitalization and eventual death satisfied no one.

Somehow, when these decisions are at hand, we need physicians that are adept at understanding not only the scientific issues but the patient’s medical narrative and the cultural context. It is another good reason to support both diversity and the medical humanities in medical education.

I didn't mean to imply that Panda wants to kill granny. Read my post. I agree with the dude. I just didn't like the title of the article. I thought it was a little sensationalistic and detracted from his main points.

It's a very difficult area, and one in which a physician can have a huge influence in either direction -- more than they realize, I'd say. I think it's incumbent on docs to address it deeply and thoughtfully, as you suggest. I know some docs -- surgeons included -- that continue to do "everything" because it's easier than making the tough decisions and having the honest conversations that those situations often require.

As one who is reaching that 60 year old mark this topic is one I think about. In reality, I think our biggest fear is not in being dead, but in the getting there. Our families want us to live forever. They want that so badly, that they unknowingly cause us to suffer much more than we need to. Are they selfish? Or, do they just not realize what is really happening? Maybe some of both?

I have made my wishes known to my family, but when it comes down to it, I worry that emotions will take over and they will go for the odds.

Im will agree with your # 1 to make sure everyone has a living will and POA. However these documents have never previously been tested with respectv to patient safety. If you get a chance read The Journal of Emerency Medicine Oct 2007 Vol 33 no3 pages 299-305. Does a livingt will equal a DNR? Are living wills compromising patient safety?

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